Do We Really Need To Assist Our Soft Tissue Mobilization with Instruments?

I received a concerning piece of mail a few weeks ago. It was an advertisement for a nearby instrument-assisted soft tissue mobilization course. It certainly wasn’t a cheap course, especially for someone who just got married and bought a new car, and is paying rent and student loans, among other bills. How they got my address to send me junk mail remains to be seen. The amount of marketing hype that IASTM has received in the past few years is extraordinary; it is impossible not to see advertisements for new courses and new tools, and discussions about the best companies and the best techniques on social media circles. Every day there is a new tool that someone is selling. But do you really need to throw down hundreds of dollars for a shiny hunk of metal? How valuable is the information being taught in continuing education classes? Is instrument-assisted soft tissue mobilization worth your time and money? For me to definitely say yes, here is what I would need to see: in a fair test, does instrument-assisted soft tissue mobilization result in significantly better clinical outcomes than traditional approaches to soft tissue mobilization? And that is putting aside the question of how much value soft tissue mobilization provides in the overall treatment of musculoskeletal conditions.

Like other fashionable treatments, the claims surrounding IASTM range from humble to outrageous and from plausible to doubtful. Broadly, it is said that IASTM can break down restrictive tissue, decrease pain, improve motion, restart the healing process and ultimately improve function, but more specific claims vary by company. Each purveyor has their own philosophy on exactly how their technique works, why it is different from their competitors, and why they need you to sign up for their course and not the others. And, of course, their technique is trademarked and patented to protect their brand and financial interests. Some of theses companies include Graston, ASTYM, and Rocktape, among many others, both big and small. Let’s go specifically into claims from these three companies.

Confident, Unsubstantiated Claims

According to Graston’s website, the Graston technique “is an innovative, evidence-based form of instrument-assisted soft tissue mobilization that enables clinicians to detect and effectively break down scar tissue and fascial restrictions, as well as maintain optimal range of motion.” As for a mechanism for how this works, they suggest that causing targeted microtrauma to the tissue in question can restart the healing process and ultimately help the tissue remodel. In addition, it is said that utilizing Graston techniques allow clinicians to enhance their detection of soft tissue lesions, reduce any stress that traditional manual therapy would place on your hands, and improve patient outcomes. According to ASTYM’s website, the ASTYM technique or augmented soft tissue mobilization “is a therapy that regenerates healthy soft tissues (muscles, tendons, etc.), and eliminates or reduces unwanted scar tissue that may be causing pain or movement restrictions.” They utilize tools to scape and massage the area in question with the goal of restarting the healing process and to organize “messy” tissue that is the supposed cause of pain and dysfunction. Despite obviously sounding just like good ole’ IASTM, they are very quick to differentiate themselves from IASTM. They suggest ASTYM technique is different in “goals and application,” but any actual differences remain to be seen. They also suggest strengthening exercises, stretching exercises and remaining active are part of the treatment. Rocktape, another company that has recently jumped into the fray, has taken a slightly different route and suggests that their tools are “a revolution in IASTM.” To their credit, they seem to acknowledge the role of the nervous system in whatever soft tissue treatments are thought to do, in addition to mechanical effects. They suggest that soft tissue work with Rockblade tools is one part of their overall system, which includes kinesiology taping and corrective exercises.

Each company claims to be evidence-based and has a section on their website dedicated to many kinds of research of varying quality. More prevalent however, is information on how to get certified,where the next course is going to be, how much money all their products cost. This type of behavior generally leaves a bad taste in my mouth, but I can appreciate the attempt to make things evidence-based. In order to truly assess if the claims made by these companies are true, we need to get into the research. Before we do however, let’s review what I will consider a fair test for them. Deciding on a fair test beforehand is absolutely critical; we need to all agree on what claims are being made and how we could test them optimally, while eliminating bias and non-specific effects as much as possible (Evans, 2011). The ideal clinical trial would be an adequately powered study comparing two groups of patients with a given musculoskeletal condition; one group would get traditional multimodal physical therapy care and any soft tissue work would be done manually, and the other group would be identical, except soft tissue work would be done with a tool. Outcomes could include pain as measured on a VAS, range of motion, and a validated functional outcome measure. Putting basic science studies for biological plausibility aside for the moment, a study of this sort, and perhaps multiple ones synthesized into meta-analyses, would be the strongest evidence any one company could have. They need to prove to me that this treatment is better than current, traditional approaches to STM, and thus worthy of my time and money. Are there any studies like this?

Fair Tests

Not really. Here is one attempt though. In a small study of twenty patients with carpal tunnel syndrome, the authors compared Graston Technique with manual soft tissue mobilization, as included in a multimodal therapy program. They found that both groups improved, and while the lack of statistical power prevented them from making strong conclusions, the improvements were similar between groups (Burke, 2007). In another study of 143 patients with thoracic pain, the authors compared the effects of spinal manipulative therapy, Graston Technique, and detuned ultrasound therapy as a placebo group. They found that although all the groups improved, there were no differences between any group on the VAS and ODI scores at any time point (Crothers, 2016). In a revealing study of eleven participants, researchers assessed the effects of IASTM on plantarflexors and measured “musculotendinous stiffness (MTS), passive range of motion (PROM), and maximal voluntary contraction peak torque (MVPT), perception of functional ability questionnaire (PFAQ) responses, and intramuscular levels of interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) myokines[indicators of inflammation]” (Vardiman, 2015). The researchers found no differences between the test leg and the control leg for any of the subjects and for any of the outcome measures, i.e. IASTM was not able to modify any musculoskeletal properties or initiate the inflammatory process (Vardiman, 2015).

A systematic review from 2016 looked at seven IASTM studies all with varying treatment protocols and comparison groups. Only one study compared IASTM to an appropriate control group; manual STM (the Burke 2007 study), and the others compared it to inactive control groups, exercise only groups, or chiropractic care. None of the studies looked at were home runs; most suggested that IASTM resulted in similar outcomes to other treatments. The authors concluded “the current research has indicated insignificant results which challenges the efficacy of IASTM as a treatment for common musculoskeletal pathology, which may be due to the methodological variability among studies” (Cheatham, 2016).

In a “systematic review” from 2016 posted on Graston’s research section, titled “Instrument-assisted Soft Tissue Manipulation: Evidence for its Emerging Efficacy,” authors Loghmani and Bane go through the various rat studies, pre-clinical studies, case reports, and the few trials that exist. Though the authors admit this was not intended to be a thorough and exhaustive review, the authors performed a decidedly causal literature search without documented search criteria, and had a relatively low bar for what studies could be included. Citing the lukewarm results of these studies, the authors conclude “thirty-seven articles were included which, although difficult to compare due to differences in techniques and study designs, indicate the beneficial effects of IASTM. Various levels of emerging evidence suggest the efficacy of IASTM as a mechano-therapeutic intervention, however, more well-designed studies with larger samples sizes, including randomized controlled clinical trials, are needed to further substantiate its efficacy and establish its effectiveness” (Loghmani, 2017). Looking at the language used throughout the article, the search strategy employed, and the lack of statistical rigour makes the article read as a hopeful endorsement of IASTM and future research rather than an honest questioning of its effectiveness. Graston’s inclusion of this study in the “Systematic Review” section is somewhat imprecise.

In another systematic review from 2017, the authors assessed seven studies on the effects of IASTM compared to other interventions for various conditions. I will tell you their conclusion first, and then we will go back and look at each study. Some of these studies were included in the review from Cheatham, but we will look at them all individually here. The authors write “the results of the studies included in this review suggest that IASTM is an effective treatment intervention for reducing pain and improving function in less than a three-month period” (Lambert, 2017). Here are the seven studies included:

• Senbursa 2007 looked at the effects of manual therapy versus a home exercise program for patients with shoulder impingement syndrome. IASTM was not part of any treatment intervention, questioning its inclusion in the review.
• Blanchette 2011 looked the effects of ASTYM versus advice, education, and basic stretching exercises on a small group of patients with lateral epicondylitis and found that while there were some differences at various time points in terms of function and pain in favor of the ASTYM group, both groups ended up in the same place. They write “this pilot study could not establish that the use of ASTM differs from the noninterventionist approach in the treatment of LE” (Blanchette, 2011)
• Lauche 2012 looked at the effects of Gua Sha therapy, an old form of IASTM, versus no treatment for 40 patients with chronic neck or back pain and found that those that received treatment had a reduction in pain of 1-2 points on the VAS after one treatment, a week later. Yes IASTM will have an effect, but is it better than what we already do? Again, I am sure practical constraints may have been an issue, but we need to see an active control group that receives a comparable intervention.
• Sandrey 2012 looked at the effects of a dynamic balance program plus Graston technique, sham Graston technique or nothing for 36 patients with chronic ankle stability and found that all 3 groups improved on each outcome measure and there were no statistical differences at any time point.
• Laudner 2014 looked at the effects of Graston technique on glenohumeral internal rotation and horizontal adduction in baseball players and found that compared to controls who received no treatment, the intervention group had improved values. While I am sure practical constraints may have influenced study design, an active control group that received a comparable intervention instead of nothing would have been favorable. Again, that is the comparison we really want to see.
• Gulick 2014 looked at the effects of Graston technique on patients with myofascial trigger points in the upper back. There were two phases. In the first, the researcher identified trigger points on both the right and left sides of each patient and treated only one side, with the other side being a control group. In the second, the research identified one trigger point in each patient and compared them to a control group of patients who received no intervention. The researcher found that in phase one, there were no differences between the effects on the treated trigger point compared to the untreated one in the same patient. Both had improved pressure sensitivity. In the second phase, there were no significant differences either, as both groups improved similarly. The author suggests this may have been due to the device used to measure pressure sensitivity and notes the study is ultimately inconclusive.
• Markovic 2015 looked at the effects of foam rolling versus Fascial Abrasion Technique on hip and knee range of motion for 20 soccer players and found that both groups improved their passive straight leg raise and knee flexion testing, but the FAT group did slightly better. This study had a few methodological concerns, i.e. small sample size and no blinding of assessors, but did have a positive result in favor of IASTM.

This brings us back to the conclusion “IASTM is an effective treatment intervention for reducing pain and improving function.” I think we have two different definitions of “effective.” If by effective, the authors mean the treatment had effects, then sure. But the comparison is what we are after. In every one of the those studies, there was always a catch; an invisible asterisk on the results that makes you just a bit curious. The effects were small, there wasn’t an appropriate control group, there were no differences from a properly designed control group, the study lacked statistical power, the list could go on. To their credit, the authors do suggest that stronger research is needed, but I think their conclusion was a little too hopeful. A more accurate conclusion could have read like this:

“IASTM may be an effective treatment for the reduction of pain, but a paucity of rigorous trials and significant statistical heterogeneity among existing trials limits our ability to draw conclusions on the effectiveness of IASTM as compared to other common physical therapy treatments. IASTM has thus far failed to demonstrate its value at this time.”

In plain English; we don’t have enough strong science to say IASTM is worth your attention.

Alternative Explanations

I have chosen not to dive into the numerous case reports and rat studies that can be found with a less restrictive literature search; it is clear that IASTM will have some specific or nonspecific effects on our patients. You can search right now and find studies that suggest IASTM is beneficial, but every new treatment will have those studies. That is not what we are after here. We need to compare IASTM to existing treatments, particularly manual soft tissue work, and assess if it is better. There just aren’t that many studies that do it. In addition, the proposed mechanism by which IASTM works (i.e. the breaking down and remodeling of scar tissue) has very questionable biological plausibility. Human beings aren’t made of clay that can be sculpted with hands, or a stainless steel tool that looks like a weapon. Some companies have taken a decidedly more neurological view, to their credit, but a more biomechanical approach is still common practice. Going into the exact mechanism of how IASTM works though, is beyond the scope of my intent.

This finally brings us back to my original question. Do we really need to assist our soft tissue mobilization with instruments to get better outcomes? It is clear to me that we have no reason to answer in the affirmative. IASTM has thus far not been shown to be better than anything else that we do, and the anecdotal reports of the treatment being easier on your hands and an improved ability to detect soft tissue lesions are just that; anecdotal. Here is an alternative narrative that would explain why we see plenty of anecdotal support, happy patients, and unconvincing research. IASTM has a proposed treatment mechanism that is plausible to the average patient and is given by many caring and enthusiastic healthcare professionals that truly do want to help. In addition, it has a certain appeal to it. It is sophisticated, relatively new, and getting through a treatment can be like a badge of honor. It is probably at least as effective as manual soft tissue mobilization and perhaps moreso when a patient is “sold” on the concept. The effects we see are likely the result of contextual and psychological factors, combined with novel sensory input, which can result in small reductions of pain and improved function. While IASTM clearly does have effects that we might care about it, it is not the only treatment that does and therefore remains largely dispensable. We have no reason to believe some of the stronger claims brought forth by the purveyors of these tools. The burden of proof is on them to show me something more impressive.

References

1. Blanchette, M., & Normand, M. C. (2011, 02). Augmented Soft Tissue Mobilization vs Natural History in the Treatment of Lateral Epicondylitis: A Pilot Study. Journal of Manipulative and Physiological Therapeutics, 34(2), 123-130. doi:10.1016/j.jmpt.2010.12.001
2. Burke, J., Buchberger, D. J., Carey-Loghmani, M. T., Dougherty, P. E., Greco, D. S., & Dishman, J. D. (2007, 01). A Pilot Study Comparing Two Manual Therapy Interventions for Carpal Tunnel Syndrome. Journal of Manipulative and Physiological Therapeutics, 30(1), 50-61. doi:10.1016/j.jmpt.2006.11.014
3. Cheatham, S. W., Matt, L., Cain, M., & Baker, . R. (2016, 09). The efficacy of instrument assisted soft tissue mobilization: a systematic review. Journal Of Canadian Chiropractic Association, 60(3).
4. Crothers, A. L., French, S. D., Hebert, J. J., & Walker, B. F. (2016, 05). Spinal manipulative therapy, Graston technique® and placebo for non-specific thoracic spine pain: A randomised controlled trial. Chiropractic & Manual Therapies, 24(1). doi:10.1186/s12998-016-0096-9
5. Evans I, Thornton H, Chalmers I, et al. Testing Treatments: Better Research for Better Healthcare. 2nd edition. London: Pinter & Martin; 2011.
6. Gulick, D. T. (2014, 10). Influence of instrument assisted soft tissue treatment techniques on myofascial trigger points. Journal of Bodywork and Movement Therapies, 18(4), 602-607. doi:10.1016/j.jbmt.2014.02.004
7. Lambert, M., Hitchcock, R., Lavallee, K., Hayford, E., Morazzini, R., Wallace, A., . . . Cleland, J. (2017, 03). The effects of instrument-assisted soft tissue mobilization compared to other interventions on pain and function: A systematic review. Physical Therapy Reviews, 22(1-2), 76-85. doi:10.1080/10833196.2017.1304184
8. Lauche, R., Wübbeling, K., Lüdtke, R., Cramer, H., Choi, K., Rampp, T., . . . Dobos, G. J. (2012, 01). Randomized Controlled Pilot Study: Pain Intensity and Pressure Pain Thresholds in Patients with Neck and Low Back Pain Before and After Traditional East Asian “Gua Sha” Therapy. The American Journal of Chinese Medicine, 40(05), 905-917. doi:10.1142/s0192415x1250067x
9. Laudner, K., Compton, B. D., McLoda, T. A., & Walters, C. M. (2014). Acute Effects Of Instrument Assisted Soft Tissue Mobilization For Improving Posterior Shoulder Range Of Motion In Collegiate Baseball Players. International Journal of Sports Physical Therapy, 9(1), 1–7.
10. Loghmani, T., & Bane, S. (2016). Instrument-assisted Soft Tissue Manipulation: Evidence for its Emerging Efficacy. Journal of Novel Physiotherapies, S3. doi:10.4172/2165-7025.s3-012
11. Markovic, G. (2015, 10). Acute effects of instrument assisted soft tissue mobilization vs. foam rolling on knee and hip range of motion in soccer players. Journal of Bodywork and Movement Therapies, 19(4), 690-696. doi:10.1016/j.jbmt.2015.04.010
12. Sandrey, M. A., & Schaefer, J. L. (2012, 11). Effects of a 4-Week Dynamic-Balance-Training Program Supplemented with Graston Instrument-Assisted Soft-Tissue Mobilization for Chronic Ankle Instability. Journal of Sport Rehabilitation, 21(4), 313-326. doi:10.1123/jsr.21.4.313
13. Senbursa, G., Baltacı, G., & Atay, A. (2007, 02). Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: A prospective, randomized clinical trial. Knee Surgery, Sports Traumatology, Arthroscopy, 15(7), 915-921. doi:10.1007/s00167-007-0288-x
14. Vardiman, J., Siedlik, J., Herda, T., Hawkins, W., Cooper, M., Graham, Z., . . . Gallagher, P. (2014, 10). Instrument-assisted Soft Tissue Mobilization: Effects on the Properties of Human Plantar Flexors. International Journal of Sports Medicine, 36(03), 197-203. doi:10.1055/s-0034-1384543
15. https://www.astym.com/Main
16. http://www.grastontechnique.com/home
17. http://www.rocktape.com/

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